Autologous tendon graft for non-union distal clavicle fracture in a patient with chronic kidney disease

BACKGROUND: Fracture of distal-end accounts for 20% of all clavicle fracture. In the situation of impaired bone healing environment such as chronic kidney disease (CKD), nonunion rates after surgery might increase. In the case where bone healing is unexpected, biological healing with tendon graft could be an alternative method to maintain bone reduction. PRESENTATION OF CASE: A 62-year old male with a history of end-stage CKD presented to the hospital with pain, wound, and deformity on the right shoulder. The patient have had surgery in the past 4 months and resulted in a non-union fracture of the distal third right clavicle. The patient underwent implant removal and continued with coracoclavicular ligament reconstruction with autologous tendon grafts of semitendinosus tendon and mini-plate augmentation. DISCUSSION: The Distal clavicle has a high rate of delayed and nonunion even without the presence of comorbidity. A compromised bone quality frequently leads to failed osteosynthesis in patients with end-stage renal failure. In the advanced stages of kidney disease, problems with a renal clearance of phosphate and low 1ɑ-hydroxylase levels resulting in increased serum phosphate levels and low serum calcium levels. Given these circumstances, we considered the idea to maintain fracture reduction by biologic soft tissue healing of the graft to replace the coracoclavicular ligaments as we can not rely on normal bone strength and healing capacity. CONCLUSION: In the situation where bone healing is unexpected, biological healing with tendon graft may be necessary. The use of autologous tendon graft and mini-plate suture augmentation could help to maintain bone reduction in such environment.